Domestic Financing for Health in Africa: The Road of Sustainability and Ownership

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Domestic Financing for Health in Africa: The Road of Sustainability and Ownership Prof Alan Whiteside The Global Fund Satellite Meeting Cape Town 7 December 2013

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Presentation delivered by Prof Alan Whiteside at the 17th ICASA Conference in Cape Town, South Africa as a panel participant on ‘The End of AIDS: Myth or reality?'

Transcript of Domestic Financing for Health in Africa: The Road of Sustainability and Ownership

Page 1: Domestic Financing for Health in Africa: The Road of Sustainability and Ownership

Domestic Financing for Health in Africa: The Road of Sustainability and

Ownership

Prof Alan Whiteside

The Global Fund Satellite Meeting

Cape Town

7 December 2013

Page 2: Domestic Financing for Health in Africa: The Road of Sustainability and Ownership

Outline

1. Where we are: AIDS, TB and Malaria in epidemiological terms:

• Global burden of disease

• A Southern African example

• AIDS and malaria a major issue

2. What we need for 2014 – 2016

3. Two tipping points

• The economic transition theory

• The epidemiological and advocacy transition theory

• Real data

4. This meeting

Page 3: Domestic Financing for Health in Africa: The Road of Sustainability and Ownership

Years of life lost (women) by cause: Global, 2010

Source: 2010 Global Burden of

Diseases Study

http://www.healthmetricsandevaluation.

org/

0-1 1-4 5-14 15-24 25-49 50 – 80 +

Age

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Years of life lost (women): Western Europe 2010

Source: 2010 Global Burden of Diseases Study

http://www.healthmetricsandevaluation.org/

Maternal

Neonatal

HIV & TB

0-1 1-4 5-14 15-24 25-49 50 – 80 +

Age

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Years of life lost (women): Western Africa, 2010

Source: 2010 Global Burden of Diseases Study

http://www.healthmetricsandevaluation.org/

Maternal

Neonatal

HIV & TB

0-1 1-4 5-14 15-24 25-49 50 – 80 +

Age

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Years of life lost (women): Central Africa, 2010

Source: 2010 Global Burden of Diseases Study

http://www.healthmetricsandevaluation.org/

Maternal

Neonatal

HIV & TB

0-1 1-4 5-14 15-24 25-49 50 – 80 +

Age

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Years of life lost (women): Eastern Africa, 2010

Source: 2010 Global Burden of Diseases Study

http://www.healthmetricsandevaluation.org/

Maternal

Neonatal

HIV & TB

0-1 1-4 5-14 15-24 25-49 50 – 80 +

Age

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Years of life lost (women): Southern Africa, 2010

Source: 2010 Global Burden of Diseases Study

http://www.healthmetricsandevaluation.org/

Maternal

Neonatal

HIV & TB

0-1 1-4 5-14 15-24 25-49 50 – 80 +

Age

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Ante-natal prevalence South Africa

1990-2011

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HIV Prevalence Among Pregnant Women: Botswana

37.4%

33.4% 32.4% 33.7%31.8%

30.4%

0%

5%

10%

15%

20%

25%

30%

35%

40%

2003 2005 2006 2007 2009 2011

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What is needed for ATM 2014- 2016

• Estimated funding required $87 billion

• Available estimated funding $76 billion or 87%

– Domestic $23 billion certain

– Global Fund $12 billion: pledging 2- 4th December

– Domestic $14 billion potential

– International $10 billion very likely $24 billion hoped for

• Mind the gap: $13 to $39 billion

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International Funding Uncertain

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Global Priorities Changing: Post 2015 MDG

High Level Panel Report

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How to sustain an HIV/AIDS Response?

1. Increase donor support: getting more from

existing donors or involving new donors

2. Increase government support

3. Decrease the cost of the current response by

improving efficiencies in existing programs

But prevent new infections!

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Criteria for Investment in Health and ATM

• Level of national income, GDP or GNI. An approximation of

resources available within a country

• Degree to which the Government is able to raise revenue through

taxes, levies, domestic borrowing, or other means.

• Proportion of Government budget devoted to debt

• Pre-existing pattern of disbursement to different sectors. For health

if historical allocations have been low, infrastructure may be poor

reducing the short-run capacity to absorb rapid increases and convert to

service delivery.

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Plan for Analysing “Fiscal Space”

• Macroeconomic analysis – Evaluating potential resource needs and resource

availability, identifying future resource gaps and potential ways of eliminating such financial gaps.

• Microeconomic analysis – Assessing potential opportunities to make the 3

largest interventions efficient:

• ART

• PMTCT

• OVC

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New Infections Deaths of HIV Positive People

Understanding Curves: New Infections and

Deaths

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Treatment needed

People Requiring

Treatment

Treatment Requirements

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New Infections Deaths of HIV Positive People

Economic Transition

Credit Mead Over

Economic Transition

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Data from South Africa

0

1000000

2000000

3000000

4000000

5000000

6000000

7000000

1985 1990 1995 2000 2005 2010 2015 2020 2025

HIVinfections

AIDS cases

AIDS deaths

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Data from South Africa

0

100000

200000

300000

400000

500000

600000

700000

1985 1990 1995 2000 2005 2010 2015 2020 2025

New infections(Incidence)

AIDS deaths

No Economic Transition

on the horizon

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New Infections Deaths of HIV Posive People

Treatment New people needing treatment

An Advocacy and

Epidemiological Transition

Epidemiologic Transition

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New Infections Deaths of HIV Posive People

Treatment New people needing treatment

Epidemiologic Transition

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Table 1: Domestic Investment 2011: % of total government expenditure

Rwanda 23.7%

Togo 15.4%

Botswana 8.7%

Malawi 18.5%

Zambia 16.0%

Nigeria 7.5%

Kenya 5.9%

Tanzania 11.1%

Source: UNAIDS, Oxford Policy Management and Authors own

calculations

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Summary of three diseases

Source US $ billions

75% of an alcohol levy 3.9

Contributions from high-revenue enterprises 2.4

Airline levy by all African countries 1.7

2% of public sector budgets earmarked for AIDS 2.4

Mobile phone levy 2.0

1% income tax levy earmarked for AIDS 3.1

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Recommendations 1

• Need for better data. We are not clear on who is spending what. This is true of

both domestic and international funding. Data needs to be improved and accessible.

• Political leadership is critical, and we need to develop advocacy messages to

ensure that health continues to be a priority.

• Revisit the economic arguments for health, including the macro-economic ones.

• Address rigid budgeting practices making it hard to reallocate revenues toward

health.

• Empowered Health officials to talk to finance and finance to understand health

• Address the perception that “donors will take care of the AIDS program”.

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Recommendations 2

• Recognized and improved the role of civil society .

• The core question: it is possible to define the “right” mix of domestic and

international investment in any country. Initial thoughts this will vary country by country.

• We should establish on a country by country basis an acceptable “benchmark” for

countries to invest from their own resources.

• The Global Fund should work with other key donors as a „thought leader‟. In

particular it should look to providing data and information.

• This is a complex political question not just an economic one

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Conclusions

1. Treatment is crucial

Medical

Moral

Ethical

Economic

2. Prevention is essential

We have to turn off the tap

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This meeting is about

how do we find

innovative ways of

mobilising more

resources?

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Thank You